Elsevier

Mayo Clinic Proceedings

Volume 85, Issue 9, September 2010, Pages 785-790
Mayo Clinic Proceedings

ORIGINAL ARTICLE
A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism

https://doi.org/10.4065/mcp.2010.0250Get rights and content

OBJECTIVE

To examine operative outcomes after acute pulmonary embolectomy (APE), a recently adopted, more aggressive surgical approach.

PATIENTS AND METHODS

We retrospectively identified patients who underwent surgical APE from April 1, 2001, through March 31, 2009, and reviewed their clinical records for perioperative outcome. Operations were performed with normothermic cardiopulmonary bypass and a beating heart, absent a patent foramen ovale. For completeness, embolectomy was performed via separate incisions in the left and right pulmonary arteries (PAs) in 15 patients.

RESULTS

Of the 18 patients identified, the mean age was 60 years, and 13 patients (72%) were men. Thirteen patients (72%) had been hospitalized recently or had systemic disease. The preoperative diagnosis was established by echocardiography or computed tomography (or both). The median (range) follow-up time for all surviving patients was 16 months (2-74 months). Indications for APE included cardiogenic shock (n=12; 67%) and severe right ventricular dysfunction as shown by echocardiography (n=5; 28%). Seven patients (39%) had an embolus in transit. Seven patients (39%) experienced cardiopulmonary arrest before APE. Four early deaths (22%) occurred; all 4 of these patients had preoperative cardiopulmonary arrest, and 2 had APE via the main PA only, without branch PA incisions. Two late deaths (11%) occurred. Right ventricular function improved in all survivors.

CONCLUSION

The results of emergent APE are encouraging, particularly among patients without cardiopulmonary arrest. It should not be reserved for patients in extremis; rather, it should be considered for patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse.

Section snippets

PATIENTS AND METHODS

All patients in this study gave authorization to be involved in clinical research. The Mayo Clinic Institutional Review Board approved this retrospective study, waiving the requirement for study-specific consent.

Medical records from April 1, 2001, through March 31, 2009, were searched to identify patients with acute PE who underwent emergency APE at Mayo Clinic (Rochester, MN). Data abstracted from the patient records included medical history, clinical notes, surgical notes, and

RESULTS

Eighteen patients met the inclusion criteria for the study. Patient characteristics are presented in Table 1. The diagnosis of massive PE was established by echocardiography or computed tomography (or both) (Figure 1). The principal indications for APE were cardiogenic shock (n=12; 67%), severe RV dysfunction as shown by echocardiography (n=5; 28%), and large PFO (n=1; 6%) (Table 2). Seven patients (39%) had an embolus in transit, including one in transit across a PFO (Figure 2). Fifteen

DISCUSSION

Acute PE remains a remarkably common clinical problem, with an average annual incidence of venous thromboembolism in the general population of the United States estimated at 1 per 1000 (approximately 250,000 incident cases).9, 10, 11 Although most patients recover with anticoagulation therapy alone,5 a subset of patients with massive APE ultimately experience hemodynamic collapse and die.12, 13 The ideal therapy for patients with documented PE is medical management with heparin derivatives and

CONCLUSION

Although most patients with acute PE respond to medical therapy, many die of persistent pulmonary vascular obstruction and right-sided heart failure. The current results of surgical embolectomy, particularly when performed with attention to complete embolectomy via separate incisions in the right and left pulmonary arteries, are encouraging. Because the mortality rate remains high among patients who undergo surgery after PEA, better stratification of patients at risk of catastrophic

REFERENCES (27)

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    The analysis has been reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [25]. Our literature search yielded 56 studies involving 1,579 patients who underwent 1,590 SPE operations [6–8, 13, 16, 26–76]. Supplemental Table 8 details the PRISMA checklist.

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    Another series of 29 patients with submassive PE calculated an 89% survival rate after pulmonary embolectomy.113 Based on similar results, Sareyyupoglu and colleagues114 concluded that embolectomy should be considered earlier in the course of the disease, including during submassive PE. Current guidelines regarding embolectomy are discordant, but the procedure may regain some of its favor as mortality decreases and patient selection continues to improve.

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This article is freely available on publication.

1

Dr Sareyyupoglu is now with The Heart Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA

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